Intensive interaction has become a popular intervention for working with people labeled with profound and multiple learning disabilities and/or autism.
Hutchinson and Bodicoat describe intensive interaction as an approach that “uses pre-verbal communication techniques for instance responsive eye contact, facial expressions, vocal mirroring and joint focus activities (Nind & Hewett 2001)” (Hutchinson and Bodicoat, 2015:1).
Despite its popularity and pervasive use in services, the authors suggest that the evidence for the effectiveness of intensive interaction has not been systematically reviewed. Here they address that gap.
The authors further describe intensive interaction as ‘a communication technique for people who do not use words’ (Hutchinson and Bodicoat, 2015:1). As such the approach has also been used to support the communication of people living with dementia. While some of the literature makes a distinction between the aims of intensive interaction as either a mechanism for communication or as route to social engagement and inclusion, Firth’s (2009) ‘Dual Access Process Model’ suggests that while the development of social engagement may reach a plateau, communication can develop long term. The literature also suggests that intensive interaction may reduce ‘self-injurious’ and ‘repetitive’ behaviours.
The paper addresses the following questions:
- What are the effects of using Intensive Interaction with a person with an intellectual disability or autism on social communication, self-injurious behaviour and repetitive behaviour?
- Are these effects influenced by the training of practitioners or staff experience?
The authors describe in detail the data-bases and key search terms they used to carry out the systematic review, including inclusion and exclusion criteria and quality assessment.
The results are presented through the following themes: training of practitioners, effectiveness of intensive interaction, staff experience, anecdotal evidence and sustainability of interventions.
The authors found that outcomes for practitioners did not vary according to the amount of training the received, but were influenced by subsequent support (or lack of it) from managers.
In terms of the effectiveness off the interaction, the evidence was limited by the lack of baseline data before the intervention was implemented. While there was a general perception that intensive interaction is an effective intervention, the authors were unable to find significant evidence for this perception.
However, they did discover a number of moving and rich anecdotal reports of increased communication, although, within the context of a systematic review, these were discounted as offering ‘insufficient evidence’.
The authors found that there was a perception that it was important to sustain the intervention for it to be effective.
The article concludes by suggesting that studies using tools of measurement in the context of intensive interaction can feel reductionist.
The authors suggest that it may be possible to capture better the rich anecdotal evidence, dismissed within the systematic review, in future qualitative research.
They encourage researchers to try to provide a robust evidence base for the perceived benefits of intensive interaction.
Strengths and limitations
This review sets out to explore the evidence base for an intervention that has become mainstream in contemporary learning disability and autism services. It seems common sense to suggest that any claims for the effectiveness of an intervention should be supported by a robust evidence base, especially when, in austere times, resources are limited and such interventions have become increasingly commodified (Mallett & Runswick-Cole, 2012).
However, intensive interaction is concerned with that most nebulous of things – human communication. The systematic review reflects on the difficulties of quantifying the minutiae of subtle, yet, for the individual and those close to them, potentially significant changes.
The authors usefully suggest how the adoption of qualitative approaches, that are not inherently reductionist, might allow research to capture some of these changes. Given the complexities of communication, it may be that stories are, perhaps, the best ways to capture human experience.
Like the majority of papers reviewing interventions for people with learning disabilities and/or autism, there is an implicit assumption here that intervention is a good thing. While this assumption is certainly part of the dominant discourse of learning disability and/or autism, this view is not shared universally. Take for example, Damian Milton’s (2014) discussion of interventions for people with autism. Milton suggests that when assessing the impact of any intervention in the lives of people with autism we should first ask:
- What is it all for?
- What is one trying to achieve and why?
- Are there ethical issues regarding these purposes, or the means by which one tries to achieve them? (Milton, 2014: 7)
Engagement with these questions seems an important pre-requisite for evaluating interventions in the lives of people with learning disabilities and/or autism.
Furthermore, the conflation of intensive interaction with the aim of reducing a person’s repetitive behaviour made within this paper is an assumption that is not universally shared by other writers in the field. Indeed, Caldwell suggests that when engaging in intensive interaction, far from trying to stop repetitive behaviours, people should use them to gain access to the child or adult communication partner’s attention.
While Milton is broadly sympathetic to intensive interaction, particularly as articulated by Caldwell, he argues convincingly that there is no ‘one size fits all approach’ and that it is important to consider ‘the views of autistic people and their families regarding what one wishes to intervene with in the first place’ (Milton, 2014: 11).
This paper usefully argues for further qualitative research to try to capture the effectiveness of intensive interaction as an approach for developing communication. Given Milton’s comments above, it also seems crucial that a review of any of interventions offered in the lives of people with learning disabilities and/or autism begins by addressing the questions of what the intervention aims to achieve, why and for whose purposes.
Hutchinson, N. and Bodicoat, A. (2015) The Effectiveness of Intensive Interaction, A Systematic Literature Review, Journal of Applied Research in Intellectual Disabilities, [abstract]
Caldwell, P (2014) The anger box. Hove: Pavilion Press.
Firth G. (2009) A dual aspect process model of intensive interaction. British Journal of Learning Disabilities 37, 43–49.
Mallett, R. and Runswick-Cole, K. (2012) Commodifying Autism: The Cultural Contexts of ‘Disability’ in the Academy, in Goodley, D., Hughes, B. and Davis, L.J. (eds) (2012) Disability and Social Theory, Basingstoke: Palgrave MacMillan. pp. 33-51
Milton, D. (2014) So what exactly are autism interventions intervening into, Good Autism Practice, 15 (2): 6-14.